APPLICATION FOR AN ASSISTANCE DOG

Page 1 - APPLICANT INFORMATION

This is a multi-page application that may take up to 1 hour to complete.
Some pages will not be required depending on the applicant type.

Please be sure you have reviewed all information in STEP 1:
REQUIRED INFORMATION , ELIGIBILITY REQUIREMENTS and POLICIES AND PROCESS
prior to starting this application should you not be eligible or able to apply.

You can PREVIEW the form questions by clicking on each bubble above.
Upon completion, any pages with errors will display a red colored circle on the page number.

You can SAVE your progress by clicking the box above and supplying a working email address.

The information is encrypted and saved for 1 week before being removed,

at which time you'll need to start over.

BEFORE CONTINUING* - PLEASE NOTE GEOGRAPHIC RESTRICTIONS THAT MAY APPLY TO YOU

YOU MUST LIVE WITHIN 230 MILES OF OUR FACILITY
if you are a Mobility, Facility or Skilled Home Companion Applicant.

Our facility address is:

221 N. Grampian Hills Road/Columbia, SC 29223

How many miles do you live from our facility?

Miles

BEFORE CONTINUING* - PLEASE NOTE GEOGRAPHIC RESTRICTIONS THAT MAY APPLY TO YOU

YOU MUST LIVE WITHIN 130 MILES OF OUR FACILITY
if you are a PTSD Applicant or Have a diagnosis of PTSD.

Our facility address is:

221 N. Grampian Hills Road/Columbia, SC 29223

How many miles does the applicant live from our facility?

Miles

Who is filling out this form?

I am the applicantI am a parent of the applicantI am assisting the applicant

Is the applicant over 18 years of age?

YesNo

APPLICANT NAME (Person that the dog will be assisting.)

First name of APPLICANT

Initial

Last name of APPLICANT

APPLICANT'S INFORMATION

Applicant's Address

Address Line 2

City

State

Postal Code

Best Phone # to reach applicant

Who would we be contacting at this number

Best time/day or method to contact you

Preferred (Nick)Name

Email (Please write NONE if no email)

Date of Birth

PARENT INFORMATION

If applicant has 2 parents, information on both parents must be completed.

Is there more than 1 parent of the applicant?

NoYes

Parent 1

PARENT 1 - First Name

Initial

PARENT 1 - Last Name

Home Street Address

City

State

PARENT 1 - Email

PARENT - Best Contact Phone

PARENT 1 - EMPLOYER

Years at present job

Supervisor's Name

Average Hours Worked Weekly

Parent 2

Is home address the same as parent 1?

NoYes

PARENT 2 - First Name

Initial

PARENT 2 - Last Name

Home Street Address

City

States

PARENT 2 Email

PARENT 2 - Best Contact Phone

Parent 2 - EMPLOYER

Supervisor's Name

Years at present job

Average Hours Worked Weekly

Page 2 : EMERGENCY CONTACT / PARENT & GUARDIAN / FACILITATOR

Emergency Contact Information

Full Name of Emergency Contact

Phone

Relationship

Will a facilitator be required? (Facilitators are required for clients under the age of 16.)
(A facilitator is someone who is responsible for the care and well-being of the dog when the recipient is not able to fully care for the dog on their own.)

No facilitator Yes, there will be a facilitator

FACILITATOR INFORMATION (If a service dog placement should require a facilitator)

A facilitator (someone who is responsible for the care and well-being of the dog when the recipient is not able to fully care for the dog on their own) may be required. If so, the following will be required of the facilitator:

1. Medical Release / History forms from:

a. Primary Care Provider

b. Any mental health providers

2. A current medication list

* Please type in N/A if any information is not applicable.

Name

Phone

Relationship to applicant

Street Address of Facilitator

Name of Employer

Years at present job

Supervisor's name

Hours worked weekly

Page 4 - MEDICAL PROFESSIONALS

All medical information must be noted to ensure we can properly
provide an assistance dog to fit a client's needs.

PRIMARY CARE Physician Information

Physician's Name

Type of Practice

Address of Office

Phone

Do you have ANY other medical professionals or therapists?

NoYes

List all other physicians, therapists and healthcare professionals that you currently see

or have seen in the past 12 months

THERAPIST/OTHER Medical Professionals

Name of Healthcare Professional

Type of Practice

Phone

Are you currently in therapy of ANY type?

NoYes

PLEASE LIST ALL THERAPY TYPES

(such as Physical Therapy, Occupational, Speech, Behavior, Mental Health, etc.)

that you currently are doing, or have done in the past 12 months.

Therapy Types

Therapy Type

Frequency

Goals

Page 5: PERSONAL CARE ASSISTANT (PCA) and MEDICATIONS

Do you use a Personal Care Attendant (PCA)?

NoYes

What tasks do they provide/ assist with?

Do you plan on the PCA(s) working with the dog?

NoYes

LIST ALL PCA'S BELOW (Use blue text to add additional names)

PCA Name

Schedule (e.g. M, W, F 9-11 am)

Length of relationship?

Do you take any medications?

NoYes

Medication Information

Name of Rx

Dosage

Prescriber

Reason Needed

Page 13 - REFERENCES

List three non-family members who could serve as references for you.

REFERENCE CONTACT 1

PERSON 1: Full Name

Full Address

Best contact phone

Email

Relationship to Applicant

REFERENCE CONTACT 2

Contact 2: Full Name

Full Address

Best contact phone

Email

Relationship to Applicant

REFERENCE CONTACT 3

Contact 3: Full Name

Full Address

Best contact phone

Email

Relationship to Applicant

Page 15 - CERTIFYING INFORMATION / ELECTRONIC SIGNATURE

CLIENT/DOG "TEAM TRAINING"

Note: If you are accepted as a client, you must agree to, and fulfill the following:

Be able to take time off from work /school (weekends included) for Team Training in Columbia, SC (typically 1-3 weeks.) You must be able to pay for lodging (if needed) and meals while in Columbia and you must be able to bring a personal care attendant if needed.
Must raise /pay a $5,000 tuition fee prior to your Team Training (Waived for Rob’s Best Friend Fund recipients)
Willing/Able to participate in on-going training sessions once you receive an assistance dog.
Willing/Able to come to Columbia, SC for 1 day, once a year for recertification testing (or willing to pay for a team of testers to come to you.)

Please REVIEW the statements below. You must certify each statment to be true/accurate by checking the box.

I certify that all of the above information is correct, complete and accurate to the best of my knowledge.

I certify that the information on all addendums and other documents submitted as part of this application is correct, complete and accurate to the best of my knowledge.

I certify I will update PAALS should any of the information change after this application is submitted.

I acknowledge that I have read the required pages on the PAALS website or forms page including:The INFORMATION REQUIREMENTS, ELIGIBILITY REQUIREMENTS, POLICIES AND PROCESS documentation. ( To review these things again you may click HERE to open a new browser window with the documentation on our website.)

I acknowledge that I understand that PAALS may request additional information about other household members.

I have read and understand the above Client/Dog "Team Training" section and am willing/able and agree to all items.

I have read, understand and have disclosed all recent and present medical information in the medical section above and have electronically signed the statement of my acknowledgment.

Electronic signature stating you certify the above items (Type full name) If the applicant is under 18 years of age, a parent or guardian must sign.

Page 17 - APPLICATION FEE AND INSTRUCTIONS

After the non-refundable application fee is paid - This step 2 of 3 will be completed.

YOU WILL BE BROUGHT TO A FORMS PAGE WHERE YOU CAN CONTINUE
STEP 3 AT YOUR CONVENIENCE.

Are you applying as a "Rob's Best Friend Fund" applicant?

NOYESYou qualify as a RBFF applicant if you are a: Veteran, Police Officer, Firefighter, Paramedic, other First Responder.

RBFF applicant's do not need to pay the $50.00 application fee.

You may submit your application and proceed to STEP 3 of our application process.

PAYMENT OPTIONS

How would you like to pay the non-refundable $50 fee?

CheckCredit Card

Please mail your check to: PAALS

221 N. Grampian Hills Rd

Columbia, SC 29233

* Note: Your application will not be put into the queue until your application fee is paid.

Caucasian	Black/African American	Asian
Hispanic, Latino or other Spanish origin	American Indian/Alaska Native	Other

Single	Married
Partner / In a relationship	Widow(er)
Divorced	Other

Deafness	Hearing Loss	Speech Impairment
Vision Impairment	Reduced Stamina	Memory Loss
Muscular Weakness	Slowed Physical Development	Spasticity
Limited Mobility	Slowed Mental Development	Coordination Issues
NONE OF THE ABOVE

Chronic Pain	Skin Sensitivity	Hot / Cold Sensitivity
Balance	Depression	Brittle Bones / Osteoporosis

Power Wheelchair	Manual Wheelchair	Scooter
Walker / Rollator	Crutch / Cane	Prosthesis
Leg Brace / AFO	Wrist Brace	Other
NONE OF THE ABOVE